Predictors of nonresponse to fluid restriction in hyponatraemia due to the syndrome of inappropriate antidiuresis.

BACKGROUND: Fluid restriction (FR), the first-line treatment for hyponatraemia due to the syndrome of inappropriate antidiuresis (SIAD), often does not lead to successful correction of hyponatraemia. Therefore, predictive markers of treatment response are desirable. We evaluated routinely measured serum (s) and urine (u) parameters, s-copeptin and s-mid-regional pro-atrial natriuretic peptide (s-MR-proANP), as possible predictors of FR response. METHODS: In this prospective observational study, we included patients with profound hyponatraemia (s-sodium <125 mmol L-1 ) due to SIAD. Patients were classified as FR responders (increase in s-sodium concentration of >3 mmol L-1 within 24 h) or nonresponders (increase of ≤3 mmol L-1 within 24 h). Initial laboratory parameters were compared between groups with logistic regression analysis. RESULTS: Of 106 SIAD patients analysed, 82 underwent treatment with FR; 48 (59%) patients showed a successful response to FR and 34 (41%) were considered nonresponders. High levels of u-sodium and u-osmolality were significantly associated with nonresponse to FR [odds ratio (OR) 15.0, 95% confidence interval (CI) 2.4-95.8, P = 0.004 and OR 34.8, 95% CI 1.2-1038.8, P = 0.041, respectively). The association of u-sodium and nonresponse remained significant also after adjustment for diuretic use. Lower levels of s-MR-proANP were associated with nonresponse (OR 0.03, 95% CI 0.003-0.3, P = 0.004), whereas s-copeptin was not significantly associated with response to FR. CONCLUSION: Easily measured laboratory parameters, especially u-sodium, correlate with therapeutic response and identify patients most likely to fail to respond to FR. Measurement of these parameters may facilitate early treatment choice in patients with SIAD.

Mid-regional pro-atrial natriuretic peptide and the assessment of volaemic status and differential diagnosis of profound hyponatraemia.

BACKGROUND: Hyponatraemia is common and its differential diagnosis and consequent therapy management is challenging. The differential diagnosis is mainly based on the routine clinical assessment of volume status, which is often misleading. Mid-regional pro-atrial natriuretic peptide (MR-proANP) is associated with extracellular and cardiac fluid volume. METHODS: A total of 227 consecutive patients admitted to the emergency department with profound hypo-osmolar hyponatraemia (Na < 125 mmol L(-1) ) were included in this prospective multicentre observational study conducted in two tertiary centres in Switzerland. A standardized diagnostic evaluation of the underlying cause of hyponatraemia was performed, and an expert panel carefully evaluated volaemic status using clinical criteria. MR-proANP levels were compared between patients with hyponatraemia of different aetiologies and for assessment of volume status. RESULTS: MR-proANP levels were higher in patients with hypervolaemic hyponatraemia compared to patients with hypovolaemic or euvolaemic hyponatraemia (P = 0.0002). The area under the curve (AUC) to predict an excess of extracellular fluid volume, compared to euvolaemia, was 0.73 [95% confidence interval (CI) 0.62-0.84]. Additionally, in multivariate analysis, MR-proANP remained an independent predictor of excess extracellular fluid volume after adjustment for congestive heart failure (P = 0.012). MR-proANP predicted the syndrome of inappropriate antidiuresis (SIAD) versus hypovolaemic and hypervolaemic hyponatraemia with an AUC of 0.77 (95% CI 0.69-0.84). CONCLUSION: MR-proANP is associated with extracellular fluid volume in patients with hyponatraemia and remains an independent predictor of hypervolaemia after adjustment for congestive heart failure. MR-proANP may be a marker for discrimination between the SIAD and hypovolaemic or hypervolaemic hyponatraemia.

Use of high-resolution thermography as a validation measure to confirm epidural anesthesia in mice: a cross-over study.

BACKGROUND: Effective epidural anesthesia is confirmed in humans by sensory assessments but these tests are not feasible in mice. We hypothesized that, in mice, infrared thermography would demonstrate selective segmental warming of lower extremities following epidural anesthesia. METHODS: We anesthetized 10 C57BL/6 mice with isoflurane and then inserted a PU-10 epidural catheter under direct surgical microscopy at T11-12. A thermal camera (thermal sensitivity ±0.05°C, pixel resolution 320x240 pixels, and spatial resolution 200 µm) recorded baseline temperature of front and rear paws, tail and ears. Thermography was assessed at baseline and 2, 5, 10, and 15 min after an epidural bolus dose of 50 µL bupivacaine 0.25% or 50 µL saline (control) using a cross-over design with dose order randomized and investigators blinded to study drug. Thermal images were recorded from video and analyzed using FLIR software. Effect over time and maximal effect (Emax) were assessed by repeated measures ANOVA and paired t-tests. Comparisons were between bupivacaine and control, and between lower vs upper extremities. RESULTS: Epidural bupivacaine caused progressive warming of lower compared with upper extremities (P <0.001), typically returning to baseline by 15 min after administration. Mean (±SD) Emax was +3.73 (±1.56) °C for lower extremities compared with 0.56 (±0.68) °C (P=0.03) for upper extremities. Following epidural saline, there was no effect over time (Emax for lower extremities -0.88 (±0.28) °C compared with the upper extremities -0.88 (±0.19) °C (P >0.99). CONCLUSIONS: Thermography is a useful tool to confirm epidural catheter placement in animals for which subjective, non-noxious, sensory measures are impossible.

Biological, psychological and clinical markers of caregiver's stress in impaired elderly with dementia and age-related disease.

Stress refers to the experience, produced through a person-environment transaction, that results in psychological or physiological distress. Everyday stress or hassles have a larger impact on health, in this frame caring for elderly disabled and/or demented persons have been shown to be a chronic role strain. The concept of stress and strain encompasses different levels of individual functioning (physiological, cognitive, affective, social). We studied whether 3 different distressing conditions show (i) different profiles in biological, psychological and clinical indices of stress, and (ii) different response to temporary environmental manipulation. A sample of 29 caregivers of elderly subjects temporarily institutionalized for (i) respite program, (ii) behavioral psychological symptoms of dementia (BPSD) in dementia-control and, (iii) a rehabilitation program after hip fracture, was assessed with clinical, psychological and biological measures. The BPSD appear to be the most powerful distressing factor, both at the beginning and at the end of the study. On the whole, to an improvement of patient's clinical picture, it corresponds only a partial improvement in stress indices of the caregiver. The slope of biological indices don not parallel those of psychological ones. Among psychometric indices, the pattern of recovery differentiate affective and cognitive domains. The "respite" care condition seems to be the less effective in reducing stress in the caregivers. The stress process should be considered in its different domains to allow a tailored intervention.

Inhibition of intestinal carcinogenesis in rats: effect of difluoromethylornithine with piroxicam or fish oil.

An inhibitor of ornithine decarboxylase, difluoromethylornithine (DFMO), and two inhibitors of prostaglandin biosynthesis, piroxicam and menhaden fish oil, were examined for their effect on intestinal tumorigenesis in male Sprague-Dawley rats fed a 5% fat semisynthetic diet. Each agent was given individually in one of two doses as follows: DFMO, 0.05% and 0.1% in the drinking water; piroxicam, 65 mg/kg diet and 130 mg/kg diet; and menhaden fish oil, 1.25% and 2.50% of the diet. Additional animal groups were given combinations of the lower dose of DFMO and the lower dose of either piroxicam or fish oil. Intestinal tumors were induced by sc injections of azoxymethane (AOM; CAS: 25843-45-2) at 8 mg/kg (body wt) weekly for 8 weeks. Test diets were started 1 week prior to the first dose of AOM, and the rats were sacrificed 26 weeks later. Rats that received either dose of DFMO or the high dose of piroxicam developed significantly fewer intestinal tumors compared to controls. The low dose of piroxicam and the fish oil given at either dose level had no effect. The combination of the low dose of DFMO and the low dose of piroxicam reduced tumor formation more than either dose of DFMO alone, whereas the low dose of DFMO and fish oil together was no more effective than either dose of DFMO alone. These results show that a combination of a small amount of DFMO and piroxicam, each acting through a different mechanism, exerts an additive inhibitory effect on intestinal tumor formation in rats.

Effect of diet high in beef fat on the composition of fecal bile acids during intestinal carcinogenesis in the rat.

Two groups of 20 male Sprague-Dawley rats each were given sc 8 mg azoxymethane/kg body weight and fed a normal diet or one high in beef fat. Control groups were not given azoxymethane. Fat-control animals did not excrete more total bile acids than did the normal-control group but did excrete more deoxycholic acid as the result of increased cholic acid degradation. Azoxymethane itself caused an increase in fecal bile acid concentratation but tended to reduce the level of cholic acid degradation. Fatty acid content in the feces increased in the animals on the fat diet but was not affected by azoxymethane. A fat-diet-dependent increase was apparent in total fecal neutral steroids and a carcinogen-dependent increase in cholesterol degradation. Dietary fat and bile steroids altered by gut microflora were important interrelated factors in the intestinal carcinogenic process of this animal model.

Effect of dietary beef fat on intestinal tumor formation by azoxymethane in rats.

Two groups of 20 male Sprague-Dawley rats each were given azoxymethane subcutaneously (8 mg/kg body wt) and fed a normal diet or one high in beef fat. Control groups were not given azoxymethane. The rats on the fat diet consumed less food and gained significantly more weight than the animals on the normal diet. Those given high fat and azoxymethane developed more intestinal tumors than did the dietary controls receiving the carcinogen. Furthermore, they had a greater number of larger tumors and more metastases than did the animals fed normally. No intestinal tumors were observed in control groups not receiving azoxymethane. The results show that the diet high in beef fat enhances the carcinogenic effect of azoxymethane in the rat.

Combined inhibitors of carcinogenesis: effect on azoxymethane-induced intestinal cancer in rats.

Outbred male Sprague-Dawley CD rats were fed a complete semisynthetic diet and were given supplemental low doses (2 ppm) of selenium as H2SeO3 in their drinking water or 50 mg 13-cis-retinoic acid (13-cis-RA) and 2 g beta-sitosterol/kg diet either singly, in combinations of two, or in combinations of all three. Intestinal tumors were induced with eight weekly sc injections of 8 mg azoxymethane (AOM)/kg body weight, and inhibition of tumor formation was determined by tumor counts after 26 weeks. Noncarcinogen controls for each dietary group received eight injections of sterile water. Tumor inhibition was statistically significant in 2 groups of animals: Dietary control animals had a tumor frequency of 5.07 tumors/rat, rats receiving selenium- plus 13-cis-RA supplementation had a tumor frequency of 3.77, and those being given the combination of all three inhibitors had 2.75 tumors/rat. Analysis of fecal steroids from 3 AOM groups (dietary controls, the beta-sitosterol plus 13-cis-RA-supplemented group, and the group receiving all three additives) after 4 months of supplementation showed that the addition of beta-sitosterol to the diet had no effect on acidic or neutral steroids, regardless of the observed difference in tumor frequency. These results suggest that subpharmacologic doses of inhibitors, particularly those that inhibit the process by different mechanisms, while ineffective alone, may provide significant inhibition of tumorigenesis when used in combination.

Effect of dietary fiber on azoxymethane-induced intestinal carcinogenesis in rats.

The effect of alfalfa, bran, and cellulose on intestinal tumor formation and fecal billary steroid levels was studied in male Sprague-Dawley rats given injections of azoxymethane (AOM). Animals received weekly injections of 8 mg AOM/kg and were fed diets containing 10% fiber (wt/wt) and 35% beef fat or 20 or 30% fiber and about 6% beef fat. Control animals in each instance were fed fiber-free diets. The addition of 10% fiber to the high-fat diet did not significantly reduce the intestinal tumor frequency (average No. of tumors/rat). However, addition of 20 or 30% fiber to the 6% fat diet significantly reduced the intestinal tumor frequency. The concentration of fecal biliary steroids (mg/g dry feces) was significantly lowered in the groups with reduced tumor frequencies, whereas the total excretion of fecal biliary steroids (mg/day) did not show a similar correlation. These observations suggest that intestinal tumor frequency can be reduced by increased dietary fiber only when fat intake is not at a high level. The effect of fiber may be due to dilution of promoters and/or carcinogens in the intestinal tract.

Animal studies implicating fat and fecal steroids in intestinal cancer.

There is epidemiological and experimental evidenced that the ingestion of excessive amounts of fat enhances intestinal cancer formation. This may be due to the interaction of luminal steroids with the bacterial flora in the colon, forming carcinogens or promoting agents. Increased fecal steroids induced by drugs, diet, or by mechanical means enhance intestinal tumor formation in rats given injections of azoxymethane. The effect appears to be promotional rather than initiative. Dietary fiber inhibits carcinogenesis only when the fat content of the diet is not excessive. Apparently, a quantitative relationship exists between these two dietary elements that further studies may define for prevention of cancer in humans.

Structural requirements for stimulation of colonic cell proliferation by oxidized fatty acids.

The primary autoxidation products of polyunsaturated fatty acids are known to stimulate DNA synthesis and induce ornithine decarboxylase activity in colonic mucosa. In the present study we have determined the structural features of the oxidized fatty acids necessary for the stimulation of these two components of mitogenesis. Compounds were instilled intrarectally in either aqueous or mineral oil vehicles and 3 h later (ornithine decarboxylase activity) or 12 h later (tritiated thymidine incorporation), the animals were killed and the colonic mucosa harvested for measurement of the two parameters of cell proliferation. Hydroperoxy and hydroxy fatty acids derived from oleate and stearate were studied. Ricinoleic acid and the alpha,beta-unsaturated ketone derived from oleic acid were also investigated. The minimal requirement for stimulation of cell proliferation is the presence of an oxidized functionally adjacent to a carbon-carbon double bond. All active compounds studied were roughly equipotent, which suggests a common mediator may be involved. These results imply that, in addition to biliary steroids, the autoxidation products of unsaturated fatty acids may play a role in the enhancement of tumorigenesis by high levels of dietary fat. Furthermore, the data suggest a possible mechanism of action for the active compounds.

Importance of the fecal stream on the induction of colon tumors by azoxymethane in rats.

The effect of the fecal stream on intestinal carcinogenesis with azoxymethane was studied in male rats. Colostomies were performed approximately 2 cm distal to the cecum in 50 Sprague-Dawley rats to produce a 20-cm segment of nonfunctional large bowel; an additional 50 animals were left intact. Each of these groups was divided equally and was fed a normal diet or a diet containing 2% cholestyramine by weight. All animals were given azoxymethan s.c. At the end of 7 months all rats were sacrificed. The animals with colostomies developed significantly fewer tumors in the defunctionalized bowel than did intact animals in the same bowel segment. Cholestyramine appeared to increase the tumor yield in the large bowel of the intact animals but had no effect on the number of tumors in the defunctionalized bowel. Further, the intact animals on both dietary regimens developed a greater number of large tumors in the distal 20 cm of bowel. The results show that the fecal stream alters the carcinogenic activity of azoxymethane in the large bowel of the rat. It also appears that the carcinogen can reach its target tissue by a route other than the fecal stream.

Effect of inhibitors of tumorigenesis on the formation of O6-methylguanine in the colon of 1,2-dimethylhydrazine-treated rats.

The level of O6-methylguanine (O6MeGua) in the colonic DNA of rats treated with 1,2-dimethylhydrazine was determined. The effect of various tumorigenesis inhibitors on the formation of this modified base was also studied. Rats were given a single s.c. injection of 1,2-[14C]dimethylhydrazine. Six hr later, they were killed, and colonic DNA was extracted and analyzed by high-pressure liquid chromatography. The inhibitors tested were disulfiram (DSF), pyrazole, sodium selenite, butylated hydroxyanisole, butylated hydroxytoluene, potassium ascorbate, and 13-cis-retinoic acid. The level of O6MeGua in control rats was 29.9 [(O6MeGua X 10(6)/guanine)]. When rats were fed 0.25% (w/w) DSF, this value was reduced to 10.2, and at 0.5% DSF there was no detectable O6MeGua formed. Injection of pyrazole (40 mg/kg i.p.) 2 hr prior to 1,2-dimethylhydrazine treatment reduced the O6MeGua level to 2.4. All the other tumorigenesis inhibitors had no effect on either O6MeGua levels or the cpm/mg DNA in treated rats. With O6MeGua as a measure of the extent of initiation, these results confirm that DSF and pyrazole inhibit the initiation phase of carcinogenesis. This is to be expected as both have been shown to block the metabolism of azoxymethane, which is a crucial metabolite in the activation of 1,2-dimethylhydrazine. The other substances, all known tumorigenesis inhibitors, may act on the promotional phase of carcinogenesis and are worthy of further study for the role in cancer prevention.

Ornithine decarboxylase activity in the rat and human colon.

We have investigated the effect of age, a high-fat diet, sodium deoxycholate, and the ornithine analogue alpha-difluoromethylornithine on ornithine decarboxylase (ODC) activity in the rat colon. The relative levels of ODC activity were also determined in normal mucosa and tumor tissue from rat and human colon. The colonic ODC activity induced by intrarectal instillation of sodium deoxycholate in male Sprague-Dawley rats was highest in young animals, and it decreased with increasing age. A high level of dietary fat caused both an increased in basal colonic ODC activity and enhanced ODC induction by deoxycholate. alpha-Difluoromethylornithine given in drinking water inhibited, in a dose-dependent fashion, deoxycholate-induced ODC activity. The frequency of azoxymethane-induced intestinal tumors was also significantly reduced by alpha-difluoromethylornithine. Since colonic ODC activity is increased in carcinogenesis by known promoting agents and decreased by tumor inhibitors, this short-term assay may provide a useful system for identifying colon tumor promoters and inhibitors. The ODC activity in colon tumors of Sprague-Dawley rats was found to be significantly higher than in normal-appearing mucosa in the same animals. Similarly, ODC activity in human colon cancer was found to be higher than that of the normal-appearing mucosa in the same specimen. These results strengthen the utilization of the rat model for studies, the results of which may apply to the human situation.

Promotion of azoxymethane-induced intestinal cancer by high-fat diet in rats.

Promotional properties of a high-fat diet in intestinal cancer were studied by feeding a 30% beef fat diet to 8 groups of rats (25 rats/group) for time periods varying from 1 to 21 weeks after 8 weekly s.c. injections of azoxymethane (AOM) (8 mg/ kg). Two other groups were fed the high-fat diet, one for 8 weeks prior to and the other during AOM injections. A 5% fat diet was fed to rats when not on the 30% fat diet and to a control group of 25 animals. High fat diet increased intestinal tumor frequency up to 2-fold when given for at least 4 weeks after but not during or prior to AOM injections; this increase occurred even after a prolonged interval (10 weeks) between the last AOM injection and the high-fat diet. In general, tumor frequency increased according to the length of time animals were fed the high-fat diet after AOM. Therefore, the high-fat diet in this model exhibited most of the properties of promoters developed from murine skin cancer, thus adding support to the concept that excess dietary fat acts at the promotional phase of carcinogenesis.

In vivo stimulation of DNA synthesis and induction of ornithine decarboxylase in rat colon by fatty acid hydroperoxides, autoxidation products of unsaturated fatty acids.

The effect of intrarectal instillation of hydroperoxy and hydroxy fatty acids on colonic DNA synthesis and ornithine decarboxylase activity in male Sprague-Dawley rats was examined. A mixture of hydroperoxy-arachidonic acid isomers was prepared by methylene blue-sensitized photooxygenation. Pure 13-hydroperoxy-9,11-octadecadienoic acid was prepared by the action of soybean lipoxygenase on linoleic acid. Sodium borohydride reduction yielded the respective hydroxy fatty acids. Twelve hr after instillation of solutions of either hydroperoxy or hydroxy fatty acids, at concentrations up to 10 mM, DNA synthesis was increased in a dose-dependent fashion up to 240% above control values. The induction of ornithine decarboxylase occurred over a similar concentration range 3 hr after instillation of oxidized linoleic acid. In this case, the hydroxy acids (49-fold increase at 10 mM), were more stimulatory than the hydroperoxy derivatives (23-fold at 10 mM). Highly purified linoleic and arachidonic acids did not stimulate either activity at concentrations up to 50 mM. These data indicate that autoxidation products of unsaturated fatty acids, likely components of high-fat diets, can evoke proliferative responses in colonic mucosa. These responses may be relevant to the promotional effect of high dietary fat on colon carcinogenesis.

A further evaluation of the effect of age on striate cortex of the rhesus monkey.

The brains of 14 rhesus monkeys (Macaca mulatta) between 4 and 35 years old were examined to determine the effects of aging on the thickness, neuronal frequency, fine structure, surface area, and volume of striate cortex. The effects of aging were ascertained by comparing the striate cortex in the six monkeys between 4 and 12 years of age with that of the eight monkeys over 25 years of age. The brains of the monkeys were all fixed by vascular perfusion and except for one of the old monkeys, whose age was estimated, the exact ages of all of the monkeys are known. One micron thick sections of plastic embedded cortex from one hemisphere of each monkey were examined by light microscopy to determine the thickness of the striate cortex, and neuronal frequency was determined by counting the numbers of neurons displaying nuclei in 250 microns-wide strips passing through the thickness of the cortex. When young monkeys were compared with the old ones, no differences were found in either the thickness of the cortex or in the numbers of neuronal profiles beneath unit areas of cortical surface. This suggests that neurons are not lost with age, and when the cortices were examined by electron microscopy there was no indication that the cell bodies of neurons are degenerating, except possibly in layer 1. Serial, 30 microns-thick, Nissl stained frozen sections from the other hemisphere of each monkey were used to determine both the surface area and the volume of the striate cortex. Overall, the surface area varied between 702 and 1480 mm2, with a mean value of 956 mm2, but there was no indication that the surface area decreased with age, and the same is true for the volume of striate cortex. The conclusion is that while there is a large variation in the amount of cortex occupied by area 17, there is no indication that its thickness, volume, or number of neurons is altered by age.

Cancer of the anal canal. Model for preoperative adjuvant combined modality therapy.

An analysis of preoperative multimodality adjuvant therapy with 5-fluorouracil, mitomycin-C, and radiation therapy revealed that 38 of 45 patients (84 percent) treated were rendered free of cancer after chemotherapy/radiation therapy. No recurrence of tumor has been noted in those patients rendered free of disease by the preoperative treatment. Seven patients (15 percent) with residual macroscopic or microscopic cancer after preoperative therapy have had recurrence, all in distant sites. These seven patients have died from the disease. The prognosis for patients in this series depended on the success of the preoperative therapy in eradicating all tumor prior to surgery. Mitomycin-C and 5-fluorouracil are cytotoxic for local disease and for microscopic distant disease as well. Abdomino-perineal resection is unnecessary for patients whose primary tumor is eradicated by the preoperative therapy. The role of the relatively low dose of radiation therapy needs to be further defined.

Inhibition of azoxymethane-induced intestinal cancer by disulfiram.

Sprague--Dawley rats, both intact and colostomized animals, were given 24 weekly injections of azoxymethane. Rats were fed either Rat Purina Chow or the same diet plus 0.25% disulfiram. In the intact animals, disulfiram reduced tumors from an average of 6.3 to 0.95. The number of rats developing tumors was reduced from 100% to 60%. In colostomized animals, the reduction was from an average of 5.0 to 0.13. Marked inhibition occurred even in the defunctionalized colon. The results suggest that disulfiram blocks the metabolism of azoxymethane to methylazoxymethanol, and also that the inhibitor may act systemically.

Importance of the duration of inhibition on intestinal carcinogenesis by difluoromethylornithine in rats.

The effect of the duration and sequence of inhibition of intestinal tumor formation in rats was studied to determine whether part time inhibition has any value. Four groups of male Sprague-Dawley rats were given 8 weekly s.c. injections of azoxymethane (AOM) 8 mg/rat. Three groups were given the inhibitor, difluoromethylornithine (DFMO) in the drinking water; one for the entire 26 weeks of the study, one for the first 13 weeks only, and one for the last 13 weeks. A control group was not given the inhibitor. While the continuous treatment group developed the least number of tumors per rat (1.5 vs. 5 for controls), still both groups given the inhibitor for just 13 weeks also developed fewer tumors than controls 5 vs. 3.2 (early treatment) and 5 vs. 2.8 (late treatment). These results show that part time inhibition, including its late application, does reduce intestinal tumor formation in rats.